Update in Hospital Medicine. Update in Hospital Medicine 2009

Transcription

1 2009 Bradley A. Sharpe, MD UCSF Division of Hospital Medicine PE in Acute COPD Exacerbations Question: What is the prevalence of PE in patients with COPD who need hospitalization? Design: Systematic review, prospective studies; COPD exacerbation + evaluated for PE; Conclusion:PE common in patients with COPD exacerbations; no clear predictors (maybe cancer? Low pco2?) Comment: Interpret with caution some flaws in data; But, should strongly consider PE in all pts with COPD exacerbation (esp. if no clear inciting factor) Think Could this be a PE? in COPD exac. Rizkallah, et al. Chest 2009;135;

2 Short Take: : Cancer in Unprovoked PE? In patients with new, unprovoked PE or DVT, what is the prevalence of cancer? In a systematic review including 3300 patients with unprovoked PE or DVT, the rate of new cancer diagnoses was 10% at 12 months. Approximately 6% were diagnosed at the time of the DVT/PE with history, exam, and basic labs. Carrier M, et al. Ann Intern Med. 2008;149:323. Duration antibiotics in COPD Exac. Question: In pts with COPD exacerbations, what is the appropriate duration of antibiotic therapy? Design: Meta-analysis of 21 RCTs, 10,700 pts with mild to moderate COPD Exacerbations; Conclusion: Extended course therapy does not improve clinical outcomes in mild to mod COPD exacerbations. Comments: Well done, data clear; Careful with sicker patients, respiratory failure where 7-10 days may be more appropriate Most COPD exac can be treated with 5 days El Moussaoui R, et al. Thorax. 2008;63:415.

3 Clopidogrel + PPI after ACS Question: After ACS, does combined use of clopidogrel + PPI increase adverse events? Design: Retrospective cohort study; large VA data; 8200 pts treated w/ clopidogrel after ACS; Conclusion: Clopidogrel + PPI after ACS assoc. increased risk of death and readmission for ACS; Risk increased approx 5% (20% 25%); Comments: PPI may inhibit plt effects of clopidogrel; But retrospective, unknown confounders? What to do? Use PPI only for clear indications (ulcer, etc.) Ho PH, et al. JAMA. 2009;301(9): Short Take: : Proton Pump Inhibitors There has been a documented association between PPIs and ventilator-associated (VAP) and community-acquired pneumonia (CAP). In a retrospective review of 64,000 admits (non- ICU), use of PPIs was associated with an increased risk of hospital-acquired pneumonia (HAP). The risk increase was ~ 1.0% (from 3.5% 4.5%). Herzig SJ, et al. JAMA. 2009;301:2120.

4 Short Take: : Proton Pump Inhibitors Could there be an association between PPIs and SBP (bacterial overgrowth translocation)? In a retrospective case-control study of patients with cirrhosis and ascites, PPI use was associated with an increased risk of SBP (odds ratio 4.3). Note, ~ 50% had no documented indication for the PPI. Bajaj JS, et al. Am J Gastro. 2009;104:1130. Summary Definitely 1) Treat mild-to-moderate COPD exacerbations for 5 days. Consider 1) Pulmonary embolism in all patients with a COPD exacerbation. 2) Cancer in up to 10% of all patients with unprovoked DVT or PE. 3) Carefully the indications for PPIs as they may increase risk of ACS with clopidogrel and risk of HAP and SBP.

5 Diagnostic Tests in Syncope Question: What are the best and most cost-effective tests in elderly patients w/ syncope? Design: Retrospective cohort study; pts > 65 yo. Noted diagnostic yield, cost per test; Conclusion: Orthostatic vitals was the best test; EKG, tele, and troponin I high-yield, low cost; Others should be based on history, exam, etc. Comments: Probably should not use shotgun approach ACC: echo, stress test, for unexplained syncope ACP guidelines: only hx, exam, EKG up front Reasonable to start w/ hx, exam, orthostatics, EKG, tele, troponin Mendu ML, et al. Arch Intern Med. 2009;169:1299. Reasons for Late Discharges What is different about patients discharged after 3pm? Prospective study of 209 general medical patients revealed 4 factors associated with later (and slower) discharges: 1) Use of ambulance at discharge 2) Discharge to a facility 3) Not filling prescription 4) Procedure or consult on the final day Chen LM, et al. JHM. 2009;4:226.

6 Medications in the Discharge Summary How well do we document discharge medications in the discharge summary? In a prospective evaluation of 577 discharge summaries, many had omitted meds, 32% of which could have led to harm. Approximately 17% of all medications had no obvious medical justification (PPIs). Perren A, et al. Qual Saf Health Care. 2009;18:205. Pending Tests in Discharge Summaries Do our current DC summaries adequately document pending tests? In a retrospective study of 696 discharge summaries at 2 academic centers, pending results of tests were mentioned only 16% of the time. Approximately 10% of these were actionable. Were MC, et al. JGIM. 2009;24:1003.

7 Re-engineering engineering the Discharge Can a focused re-engineered discharge process prevent readmissions? In an RCT of 750 patients, a multi-faceted discharge process (team, nurse, pharmacist) decreased readmissions and ED visits. Jack et al. Ann Intern Med 2009;24(3): Vancomycin Treatment Guidelines Question: What are best practices for the use and monitoring of vancomycin? Design: Expert panel w/ literature review; Guidelines for dosing & monitoring Conclusion: Measure trough after 4 th dose, goal > 10mg/dL; Goal 15-20mg/dL for invasive MRSA infections; No indication to measure peak values Comments: MRSA infections increasing; Some evidence but follow expert guidelines; Consult with local pharmacist if needed Rybak MJ, et al. CID. 2009;49:325.

8 Diagnosing Clostridium difficile Question: How can we most effectively diagnose C difficile colitis in hospitalized patients? Design: Narrative expert review (Annals); Retrospective cohort study; Conclusion: Only send if 3 loose stools in a day; Many possible testing options; Generally no indication to send stool twice; Comments: C difficile is common, accurate diagnosis is key Should not be kneejerk reaction to diarrhea Figure out which test you are using (all different) Peterson LR, et al. Ann Intern Med. 2009;151:176. Nemat H, et al. Am J Gastro. 2009;104:2035. Summary Definitely 1) Follow vancomycin treatment guidelines. 2) Dictate accurate discharge medications and pending tests. Consider 1) Limited initial evaluation for syncope (orthostatics, EKG, tele, troponin). 2) Sending C diff only if 3 loose stools. Stop 1) Sending stool for C diff multiple times.

9 Intensive Glucose in the ICU Question: In a mixed med-surg ICU, what are the risks/benefits of intensive glucose control? Design: RCT, 42 ICUs, 6104 patients; ICU > 3 days; Goal mg/dl vs. < 180 mg/dl Conclusions:Tight glucose control increased hypoglycemia and mortality; true in all subgroups of patients Comment: Very well done RCT Balance risks vs. risks of hyperglycemia? Maybe goal mg/dl??? NICE-SUGAR. NEJM. 2009;360:1283. Catheter-associated associated UTI Question: How well do we diagnose real UTIs in patients with foley catheters? Design: Retrospective analysis; 280 urine cultures; All pts w/ Foley or condom cath for >24 hrs Conclusions:Up to 1/3 of pts w/o infection were given abx; Older pts, gram neg rods, higher urine WBC predicted inappropriate abx Comment: Likely are over-treating patients; cost/resist. Pyuria + bacteria alone is not enough. Think is this an infection? before you treat. CopeM, et al. CID. 2009;48:1182.

10 End of Life Recommendations Question: Should physicians recommend limitations of life support to surrogates? Design: Prospective study, 169 surrogate decisionmakers for critically ill patients; Watched videos of simulated family meetings Conclusion: Up to 40% preferred no MD recommendation Felt might make the process harder Comment: No consensus on if we should provide recs Best practice probably to ask if surrogates want a recommendation White DB, et al. Am J Respir Crit Care Med. 2009;180:320. Interpreted Family Meetings How do interpreted family meetings differ from non-interpreted family meetings? Family members from 10 interpreted and 51 noninterpreted conferences were interviewed. Families received less information and less emotional support in interpreted conferences. Thornton JD, et al. Crit Care Med. 2009;37:89.

11 Summary Definitely 1) Stop treating patients who do not have true catheter-associated urinary tract infections. 2) Be aware of the emotional support and information you provide in interpreted family meetings. Consider 1) Making goal blood sugar in the ICU mg/dl. 2) Asking surrogates if they would like you to make a recommendation regarding limits in life support For the full powerpoint presentation: sharpeb@medicine.ucsf.edu